Inquiry request form - Ordre des pharmaciens du Québec

Identification of person making the request

Genre

Ms.
Mr.
I want to make an anonymous claim.

Be careful, if you choose this option, you will not have any follow-up.

Last name

First name

Address*

Apt.

City*

Province*

Postal code*

Primary tel.*

Work tel.

Ext.

Email*

Are you the patient concerned?

Yes
No

Date of birth [yyyy/mm/dd]*

Identification of patient

Genre

Ms.
Mr.

Last name

First name

Date of birth [yyyy/mm/dd]

Email

Primary tel.

Identification of pharmacy and/or pharmacist

Name of institution (see label or receipt)

Name of pharmacist concerned (only if you know it)

Pharmacy address

Office

City

Province

Postal code

Pharmacy phone number

Witness identification (optional)

If someone was a witness of the reason why you are filling a complain, identify them here.

Witness first and last name

Relationship of witness to patient

Witness phone number

Grounds for requesting an inquiry

Do you have documents or other items relevant to the inquiry (e.g., medications, invoices, photos)?

Yes
No

Items relevant to the inquiry

Déposer les fichiers ici ou

Types de fichier acceptés : jpg, gif, png, pdf, Taille maximum des fichiers : 128 MB, Nombre maximum de fichiers : 5.

If possible, please use PDF format for the elements to be transmitted.

Relate the facts and explain the reasons that led you to make this request for an inquiry. Specify the dates, times or periods related to the events or incidents, in the order in which they occurred.

Expectations

What do you hope will happen once you’ve submitted your request?

Confirmation and follow-up

I confirm that the information provided is true to the best of my knowledge.*

I confirm that the information provided is true to the best of my knowledge.

I agree that a copy of this request (excluding my personal data) may be forwarded to the pharmacist concerned for the purpose of the requested inquiry.

I agree that a copy of this request (excluding my personal data) may be forwarded to the pharmacist concerned for the purpose of the requested inquiry.

Progress of the inquiry*

I wish to be informed of the progress and conclusion of the inquiry.
I wish to be informed of the conclusion of the inquiry only.
I do not wish to be informed of any aspect of the inquiry.)

How would you prefer to be contacted?

Email
Mail

Copy of this form

I would like to receive a copy of this form